mobility
A basketball player fell awkwardly, a mishap that has resulted in a tear to the anterior cruciate ligament. What characteristic of ligaments makes them particularly susceptible to injury? -Ligaments are incapable of accommodating lateral movement. -Ligaments are exclusive to the knee, which is the most frequently injured joint. -Ligaments are superficial to the synovial capsule and are consequently vulnerable to impacts. -Ligaments are incapable of stretching when exposed to unusual stress.
Ligaments are incapable of stretching when exposed to unusual stress. Ligaments are pliable enough to permit movement at the joints, but they tear rather than stretch when exposed to excess stress. Ligaments are not exclusive to the synovial joint of the knee. They are considered part of the joint capsule.
A client with suspected osteomalacia has a fractured tibia and fibula. What test would give a definitive diagnosis of osteomalacia? A bone biopsy Demineralization of the bone Increased and decreased areas of bone metabolism Elevated levels of alkaline phosphatase
A bone biopsy A definitive diagnosis is obtained by bone biopsy. Radiographic studies demonstrate demineralization of the bone. A bone scan detects increased and decreased areas of bone metabolism. Alkaline phosphatase levels are detected from a blood sample.
A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records? -Ineffective Movement related to arthritis I-mpaired Movements due to pain -Impaired Physical Mobility related to pain -Ineffective Physical Mobility due to pain
Impaired Physical Mobility related to pain "Impaired Physical Mobility related to pain" is the correct nursing diagnosis because it consists of an accurate descriptor, diagnostic label, and related factor. "Ineffective Movement related to arthritis" is an incorrect entry because the descriptor is incorrect and the diagnostic label is not approved. "Impaired Movements due to pain" is an inaccurate entry because the descriptor is inaccurate and the related factor is not written using approved words. "Ineffective Physical Mobility due to pain" has an erroneous diagnostic label and the related factors are written incorrectly.
A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction? "Apply ice packs for the first 12 to 18 hours." "Apply heat packs for the first 24 to 48 hours." "Apply ice packs for the first 24 to 48 hours, then apply heat packs." "Apply heat packs for the first 24 hours, then apply ice packs for the next 48 hours."
"Apply ice packs for the first 24 to 48 hours, then apply heat packs." The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.
Which actions by the nurse demonstrate an understanding of caring for a client in traction? Select all that apply. -Placing a trapeze on the bed -Ensuring that the weights are hanging freely -Assessing the client's alignment in the bed -Removing skeletal traction to turn and reposition the client -Frequently assessing pain level
Placing a trapeze on the bed Ensuring that the weights are hanging freely Assessing the client's alignment in the bed Frequently assessing pain level The weights must hang freely, with the client in good alignment in the center of the bed. The nurse should frequently monitor pain, as uncontrolled pain may be a sign of a complication. The client will be able to assist with alignment and bed mobility if a trapeze is placed on the bed. Skeletal traction should never be interrupted.
Autonomic dysreflexia (autonomic hyperreflexia) is characterized by which of the following? -Severe spinal shock -Tachycardia and pale skin -Lack of sweat above injury level -Vasospasms and hypertension
Vasospasms and hypertension Autonomic hyperreflexia, an acute episode of exaggerated sympathetic reflex responses that occur in persons with injuries at T6 and above, in which central nervous system (CNS) control of spinal reflexes is lost, does not occur until spinal shock has resolved and autonomic reflexes return. Autonomic dysreflexia is characterized by vasospasm, hypertension ranging from mild to severe, skin pallor, and gooseflesh associated with the piloerector response. Continued hypertension produces a baroreflex-mediated vagal slowing of the heart rate to bradycardic levels. There is an accompanying baroreflex-mediated vasodilation with flushed skin and profuse sweating above the level of injury.
The nurse is teaching a new graduate nurse about the most common causes of back injuries. The nurse knows that the new graduate understands the concepts of back injuries when the graduate states that back injuries: are related to sitting for long periods. can be prevented with the use of a gait belt. are a routine consequence of the job. can occur when uncooperative clients are being repositioned.
can occur when uncooperative clients are being repositioned. Many nurses believe that back pain is a routine consequence of the job, but it need not be. Employing principles of body mechanics, use of algorithms, and guidelines for transferring or lifting clients contributes to the prevention of back injuries and pain. Back injuries can occur when uncooperative clients are being repositioned. Back injuries cannot be prevented with the use of a gait belt. Inappropriate use of the gait belt and other factors can contribute to back injuries. Standing, not sitting, for long periods can contribute to back injuries.
A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what? -Inflammation -Arthritis -Crepitus -Fremitus
crepitus Problems with the temporomandibular joint include pain or a grating feeling called crepitus.
A 42-year-old client is admitted to the hospital with severe back pain, intermittent tinnitus, constant headache, and vertigo. He states that the back pain has been a problem for a number of years, but the other symptoms are quite new. Upon further examination, it is noted that he has unexplained hearing loss, and his femur and tibia have begun to bow. What condition does this client most likely have? -Rickets -Osteomyelitis -Osteoporosis -Paget disease
pagets disease The clinical manifestations of Paget disease that involve the skull result in headaches, intermittent tinnitus, vertigo, and eventual hearing loss. In the spine, collapse of the anterior vertebrae causes kyphosis of the thoracic spine. The femur and tibia also become bowed.
The nurse enters the room to do an initial assessment on a client with a fracture of the femoral head. What would be the expected findings on the affected limb? lengthening of the affected extremity with internal rotation shortening of the affected extremity with external rotation abduction with external rotation of the right leg abduction with internal rotation of the left leg
shortening of the affected extremity with external rotation As a result of the muscles contracting and pulling on the two portions of bone, there is a characteristic shortening of the femur with external rotation of the extremity. The other answers are incorrect based on pathology of a hip fracture.
Which of these is a clinical manifestation of osteoporosis? Loss of mineralized bone mass Decreased porosity of bones Inability to move joints without pain Decrease in joint mobility
Loss of mineralized bone mass Osteoporosis is a metabolic bone disease characterized by the loss of mineralized bone mass and increased porosity of bones.
Which is a circulatory indicator of peripheral neurovascular dysfunction? -Weakness -Paresthesia -Cool skin -Paralysis
cool skin Indicators of peripheral neurovascular dysfunction related to circulation include pale, cyanotic, or mottled skin with a cool temperature. The capillary refill is more than 3 seconds. Weakness and paralysis are related to motion. Paresthesia is related to sensation.
